This questionnaire will be combined with information gathered during the consultation and used to build an individual nutritional programme specifically tailored to your needs and lifestyle. Please answer the questions as accurately as you can. All personal information provided is strictly confidential.

Please complete the form in one sitting only and then submit. If you are interrupted or inadvertently submitted your form before completion, you can open a new version and start where you left off. As long as the Client Booking Reference is completed correctly, we'll match them up!

Please fill in the number of times you eat the food referred to in the questions below.

Please complete the following 3-day food diary ensuring one of the days is over a weekend, and remember to include EVERYTHING! Don’t ignore mouthfuls or handfuls.  Please indicate portion size and provide information about the food source e.g. homemade, restaurant, shop bought etc.  Our nutritional therapy sessions are non-judgmental and designed to move you forward from where you are now so as to benefit your health.  Please do not be embarrassed to write down what you eat or drink.  The more accurate information you provide the more effectively we can tailor a realistic and achievable programme for you.

Some people find it helpful to print off the diary and jot down what they eat and drink during the day, then fill it in on screen or return in the post to the clinic (ideally at least 2 weeks before your consultation) or bring it with you on the day of your appointment.

Nutritional therapy is an individual centered approach to healthcare that employs assessment and intervention using nutritional, lifestyle based and related health sciences in order to assist the individual to optimise his or her physiological (internal processes), emotional, cognitive and physical function. This is different to the diagnosis and treatment of medical conditions which is solely carried out by doctors.

The Nutritional Therapist

• will assess the individual’s general health, family history, dietary habits, digestive function and lifestyle.
• may recommend specific functional tests. A tailored suitable dietary and lifestyle plan will be identified and agreed between both parties.
• will abide by the NTOI (Nutritional Therapists of Ireland) Code of Professional Practice.

The Client

• is responsible for contacting your GP about any health concerns.
• It is important that you tell your Nutritional Therapist about any medical diagnosis, medication, herbal medicine, or food supplements you are taking as this may affect the nutritional programme. Likewise, if you are receiving treatment from your GP or any other medical provider, you should tell them about any nutritional strategy provided by the Nutritional Therapist.
• It is imperative that you contact your Nutritional Therapist if you are unclear about any aspect of the programme. The Nutritional Therapist will provide clarification on any issues you may have. You are advised to report any concerns about nutritional therapy promptly to your Nutritional Therapist for discussion and action.
• You must contact your Nutritional Therapist should you wish to continue any specified supplement programme for longer than the agreed period, to avoid any potential adverse reactions.

Discussing your expectations
We will discuss your expectations and tell you whether we think they are realistic. It is important to us that you understand at all times what is happening in your case. To help prevent any confusion or stress on your part, we will give you general information and explain any procedures regarding your programme as it progresses.

Consent
We may share your sensitive information with third parties to support your ongoing healthcare.  If we do not receive this consent from you, we will not be able to coordinate your healthcare with that provided by other providers which means the healthcare provided by us may be less effective.